This comprehensive inspection took place on 8 December 2017 and was unannounced. Gerald House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home is registered to provide accommodation and personal care to people with mental health needs. The capacity of the home is 18 and at the time of inspection there were 15 people living in the care home.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Care records and risk assessments were well-kept and up-to-date. Each person living at the home had a personalised care plan and risk assessment. Monitoring information was clear in regards to maintenance, people’s weights and daily checks that were carried out by the staff. Relatives were able to visit their family members at any time and for people that did not have friends or family to represent them, information regarding advocacy services was available within the home.

Recruitment practices were in place which included the completion of pre-employment checks prior to a new member of staff working at the service. This included checks in relation to criminal convictions and previous employment.

Staff said they felt supported and that they could approach the registered manager and deputy manager with any concerns. There was evidence of a formal supervision and appraisal process. Staff had completed training the provider deemed necessary to enable them to meet people’s needs effectively.

The staff in the home knew the people they were supporting and the care they needed. We observed staff to be kind and respectful. This was supported in discussion with people living in the home. People we spoke with said they would know how to make a complaint. None of the people we spoke with had any complaints.

We found that the Mental Capacity Act 2005 and the Deprivation of Liberty (DoLS) 2009 legislation had been followed. The provider told us that DoLS applications had been submitted to the Local Authority for some people and staff were knowledgeable about the people living in the home and their mental capacity needs.

Healthcare professionals such as GPs and district nurses were contacted for advice about people’s health needs when necessary. The provider had systems in place to ensure that people were protected from the risk of harm or abuse. There were policies and procedures in place and training to guide staff in relation to safeguarding adults.

People’s nutritional needs were assessed regularly and met by the home. When risks were identified, appropriate referrals were made for specialist advice. People told us they had enough to eat and drink and enjoyed the meals provided to them. People told us that they were given choices of what they preferred at meal times.

The registered manager and deputy manager regularly checked the quality of care at the home through mock inspections, quality questionnaires and audits and we saw that these included medication, falls and care plans.

We looked at safety certificates that demonstrated that utilities and services, such as gas and electric had been tested and were safe. Fire evacuation plans had been reviewed and updated. Personal emergency evacuation plans had been completed for all of the people who lived in the service.

This inspection was carried out on 22 and 28 July 2016, the first day of the inspection was unannounced. We carried out this inspection at this time as the home were in special measures and had been rated inadequate and we needed to check that improvements had been made

to the quality and safety of the service.

Gerald house is a detached property situated in Prenton. The home is registered to provide accommodation and personal care to people with mental health needs. The capacity of the home is 18. The home is two floors with a passenger lift. Most bedrooms have en suite facilities and there are gardens to the front and back of the property.

The home has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last comprehensive inspection of the home in January 2016 we found a number of breaches of regulations. As a result we served warning notices on the home for breaches related to the safety of the premises and its equipment, infection control, medication management, staff recruitment, training and supervision and the management of the service. We found that improvements had been made in all of these areas but minor further improvements were required. However, in response to the improvements that had been made we took the home out of special measures.

We had previously found that the provider had not had suitable systems and processes to ensure the premises and equipment were safe, suitable for use and met statutory requirements. At this inspection we found the safety of the building and equipment had improved and it provided a safe environment for people to live in.

During our last inspection we found that the provider did not have adequate arrangements in place to ensure the ordering of medicines and the way in which medicines were accounted for were safe. During this inspection we found that this had improved and the provider had implemented new procedures that were adhered to by all staff.

We had found that the provider did not have suitable systems in place to assess, monitor and prevent the spread of infection. At this inspection we found a number of improvements including the implementation of cleaning rotas.

We had found that the provider failed to assess and mitigate risks to people's health, safety and welfare. At this inspection we found a number of improvements including implementing audits and improving the systems relating to the personal allowances of the people living in the home.

Following the inspection in January 2016 we had also given the home a number of requirement actions. We required them to make improvements to staff training, supervision and recruitment. We had found that staff had not received suitable training or supervision to enable them to carry out their role effectively. At this inspection we found a number of improvements, example being that we found that staff had received formal one to one supervision and had undertaken a number of training courses. However, at this inspection we observed poor moving and handling practices.

People we spoke to were happy wih the food provided and we saw that people had a choice of nutritious meals and received support if needed to eat their meals.

There were sufficient staff working at the home to meet people’s care needs and staff were friendly, welcoming and were observed to have good relationships with each other and a kind and respectful approach to people’s care.

We found that the Mental Capacity Act 2005 and the Deprivation of Liberty (DoLS) 2009 legislation had been adhered to in the home. The registered manager told us of the people at the home who lacked capacity and that the appropriate Deprivation of Liberty Safeguard (DoL

We considered all of the evidence we have gathered under the outcomes we had inspected. We used the information to answer the five questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Is the service safe?

On the day of our visit we found the environment clean and fresh.

We saw enough staff on duty to meet the needs of the people living at the home and were told that a member of the management team was always available either working in the home or on call in case of emergencies.

People who lived in the home told us that they felt safe.

We saw training records which identified that staff received training relevant to the needs of the people who lived in the home.

Is the service effective?

People told us that they were happy with their care. We spoke with staff and found that they knew the people living in the home well. One person told us that they had decided to move to the home permanently as they felt living there met their needs. We spoke with staff and checked records and found that staff had received training to meet the needs of the people living at the home.

Is the service caring?

We spent time in all areas of the home and saw and heard staff to be kind and patient to the people who lived there. We saw that the people who lived in the home were comfortable in the company of staff and owners and happy to share a joke with them. One person told us "I’m happy here and feel safe". One person had written on the annual survey that they felt the home was "Friendly".

Is the service responsive?

People who lived in the home told us that they were happy with their care. We looked at care plans and saw that they were person centred and updated to reflect the changing needs of people. We saw that relevant referrals were made to other professionals as and when required.

Is the service well led?

We were told that the owners of the service, one of whom is the registered manager spends a lot of time in the home. People who lived in the home told us that they are always available for a chat. We saw that the owners had a continuous program of refurbishment and improvement to ensure that people lived in safe comfortable surroundings. Staff told us that the management supported them to attend training.

During our inspection we spoke with seven people who used the service and also spoke with relatives and staff. People told us; "This is a lovely place, the staff are nice and the food is good", "Being here has helped me a lot","It's like a four star hotel"and "It's good because I can do what I want, when I want and the staff are very helpful".

Relatives told us; "Staff are really kind and patient", "It's a good place, the food seems fine" and "My mind is at rest knowing dad is well looked after".

There were arrangements in place to ensure that people were able to consent to the care provided for them. We found that people's needs were assessed and that their care plans were explanatory and person centred. Daily notes were up to date and reflected information about each person appropriately. A communication book ensured that staff were aware of any significant changes to a person's care or areas of risk that may have changed. We found that people's nutritional needs were being met and there was a variety of nutritious food and drink available.

We found that the provider operated effective recruitment procedures and saw evidence that staff were trained appropriately in order to support the people they were caring for. There was an up to date Statement of Purpose which correctly reflected the services offered. Records were maintained appropriately and the provider had arrangements in place to manage and assure that the quality of the service was maintained.

The expert by experience spoke to people who used the service and their relatives. The expert by experience reported:

‘Care workers communicated with people who used the service in a respectful manner and showed concern for their welfare.’

‘Care workers promoted independence by encouraging people to go to activities in the community such as social clubs.’ Some comments were;

“I like to go out and meet different people.”

People who used the service told us they felt well looked after and involved in their care. Some comments were;

“I have continued to go out and meet friends and go to my club that was important to me that I was able to continue to live my life. But when I come home it’s nice to have the girls there to help me.”

The expert by experience reported peoples’ bedrooms rooms were personalised and homely in appearance.

Records showed the service sends out questionnaires annually to people who used the service and their family members. This was to seek their views about how the service offered support and care. We looked at last years completed questionnaires they indicated overall people were happy with the service provided.

A family member spoken with made the following comment;

“I have confidence in the staff and feel that they give my mother the best care.”

People spoken with during the inspection visit were satisfied with the care and support they received. Some comments made were;

“If I’m not feeling well K or A always get the GP for me.”

“The girls are very good they always check that I’m ok they really put themselves out for me.”

“If I was concerned about anything I would talk to K or A they are very approachable and explain things to me.”

“I’m happy here you just have to get on with it you have to learn to get on with strangers which can be difficult. But I like the size of the home not too big you get to know everyone really well including the staff. That is what I like the best.”

Observations showed care workers were respectful towards the people who used the service. Throughout the visit we observed people were treated in a friendly and dignified manner. People spoken said they were happy with the care and support they received.

Gerald House is a detached property situated in Prenton. The home provides accommodation with personal care for older adults and people with mental health needs. There are 16 individual bedrooms and one shared bedroom situated across three floors. There is a passenger lift to enable people with mobility issues to access the upper floors of the building. Most of the bedrooms have en-suite toilet facilities with specialised bathing facilities available in communal bathrooms. There is a garden area to the front and rear of the property with a small car park.

The home has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’  The registered manager was not present during our visit and did not participate in the inspection.  The assistant manager  assisted us with our inspection.

During our inspection, we identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulated Activities 2014 in respect of Regulation 12, 17, 18 and 19 of the Health and Social Care Act 2014 Regulations.

These breaches related to the safety of the premises and its equipment, infection control, medication management, staff recruitment, training and supervision and the management of the service. You can see what action we told the provider to take at the back of the full version of the report.

During our visit, we found that some areas of the home were in need of repair and improvement to ensure they were suitable for use. We found that systems at the home such as gas, fire, the nurse call bell system and the moving and handling equipment in use at the home were not appropriately maintained and inspected to ensure they were safe for use. This placed people at risk of physical harm.

We observed that staffing levels at the home were satisfactory and people who lived at the home confirmed this. We looked at five staff files. We found staff were not always recruited appropriately to ensure they were safe to work with, and had the skills and experience to care for vulnerable people. Once employed, some staff had not received adequate training or supervision to do their job role effectively. This placed people at risk of receiving inappropriate and unsafe care.

Arrangements for the administration of boxed or ‘as and when required’ medication were unsafe. Insufficient administration instructions were handwritten on people’s medication administration charts which meant that staff did not have adequate guidance on the amount of medication to administer, its frequency or its purpose. This meant there was a risk that this medication would not be given in accordance with prescribed instructions. Procedures to check that medication was stored at the right temperatures were also not in place.

The home was clean and free from odours on the day of our visit. Infection control standards at the home however required improvement. Hand hygiene facilities and the procedures for the handling of people’s laundry items were inadequate and did not adhere to the Department of Health’s 2008 Code of Practice on the prevention and control of infections. There were also no system in place for the identification and control of legionella bacteria in the home’s water system. These inadequacies placed people at increased risk of contracting an infection.

We looked at three care files and found that the majority of people’s risks were assessed and managed. Some healthcare risks such as those associated with specific medical conditions or special dietary requirements had not been properly considered in the planning and delivery of care. This aspect of risk management required improvement to protect people from harm.

Care plans were person centred and gave staff an insight into the person they were caring for. People who lived at the home with mental health needs were involved with appropriate mental health services. Where people had mental health issues however, care plans lacked adequate information on how these issues impacted on their day to day lives and decision making. Staff had also not received any specific mental health training. This meant staff at the home may not understand how to respond to and promote a person’s mental and emotional well-being.

We saw some evidence of the beginnings of good practice in relation to the Mental Capacity Act 2005 legislation. The provider had applied for a deprivation of liberty safeguard in respect of one person at the home to keep them safe. A mental capacity assessment had been undertaken. There was evidence of best interest discussions with the person and related professionals involved in their care and staff at the home had a clear strategy for minimising the restrictions placed on the person which had been agreed and implemented. We found that the requirements of the Mental Capacity Act required implementation for other people at the home with similar needs.

We looked at the opportunities for social engagement at the home and found that people’s social needs were not properly promoted to ensure a good quality of life. People we spoke with told us activities, events and outings at the service were infrequent and there was no evidence that any organised activity programme was in place. This meant there was no evidence that the provider ensured people had access to activities and interactions that promoted their emotional well-being.

People’s nutritional needs and risks had been assessed and people received sufficient quantities of food and drink. People we spoke with where happy with the quality of food provided. People told us they were happy with the care they received and said they were well looked after. They

told us that staff were kind and treated them with respect. We found the atmosphere at the home to be calm and homely. From our observations it was clear staff knew people well. Staff we spoke with had an understanding of people’s needs and preferences and spoke warmly about the people they care for. People’s views on the quality of the service had been sought in October 2015 with positive results.

Overall we found the management of the home inadequate. There were no effective systems in place to assess and manage the risks to people’s health, safety and welfare. There were no effective systems in place to ensure the quality of the service was of an appropriate standard. Policies and procedures in the majority were out of date and the management of the service was found to be ad hoc and reactive. The service was not well led and did not guarantee people received safe, effective, caring and responsive support.

At the end of our visit, we discussed the concerns we had about the service with the assistant manager. They were unable to provide a satisfactory explanation as to why the issues we identified during our inspection had not been picked up and addressed.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.